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State of California—Health and Welfare Agency Department of Health Services <br /> OFFICIAL SAMPLE RECEIPT <br /> TOXIC SUBSTANCES CONTROL DIVISION <br /> 107 South Broadway, Room 7011 4250 Power Inn Road 5850 Shellmound Street, <br /> Los Angeles, 90012 Sacramento, 95826 Suite 390 <br /> Emeryville, 94608 <br /> (213) 620-2380 (916) 739-3145 (415) 540-2043 <br /> IDa e/ <br /> Firm Name ' <br /> Ci ow-cknv) <br /> Address City ZIP Code <br /> J -S YYl Pe 0. <br /> Person Interviewed Position <br /> The items listed below were collected as official samples on this date as authorized by Section 66328, California Administrative Code, <br /> Title 22. <br /> Quantity Unit Size Material I.D. Number <br /> - <br /> I r '/z a, .. -vim� i -o <br /> �n <br /> ;i <br /> ri <br /> Receipt ackn wl d d by; <br /> ( I I �� <br /> 1 <br /> Signa ur' By <br /> Authorized Agent <br /> EH 206 (2/87) <br />